·论著·

    急性心源性肺水肿机械通气治疗效果

    及对血流动力学的影响

    展春 秦英智 张纳新 徐磊 张伟

    【摘要】 目的 研究急性心源性肺水肿(ACPE)机械通气治疗方法, 比较持续气道正压 成比例压力支

    持(CPA P PPS)、持续气道正压 压力支持通气(CPA P PSV )两种模式对血流动力学的影响。方法 77 例

    ACPE 患者进行无创、有创机械通气治疗, 对其中机械通气时间超过24 h 的61 例患者在有创机械通气开始与

    低辅助通气时用部分CO 2 重复呼吸法(无创心排血量,N ICO )监测血流动力学变化, 在药物干预下, 对照研究

    两种模式下血流动力学变化。 结果 61 例ACPE 患者中33 例行无创机械通气, 成功24 例(7217% ) , 33 例有创

    机 械通气(5 例为无创转为有创机械通气) , 11 例失败。控制通气应用双水平气道正压? 压力支持通气

    (B IPA P? PSV ) , 高水平压力(Ph igh) 16～ 24 cm H2O (1 cm H2O = 01098 kPa) , 高水平压力时间(Th igh) 115 s,呼气末正压(PEEP) 6～ 15 cm H2O , 吸入氧浓度(F iO 2) 015; 有创机械通气撤机成功患者心排血量(CO )和心排

    血指数(C I)较有创机械通气撤机失败患者明显改善, 低辅助通气采用PPS 模式患者的CO 和C I较采用PSV 模

    式患者改善更明显(P 均< 01001) , 有创机械通气撤机失败患者在药物干预下仍C I< 115 L·m in- 1

    ·m- 2。结

    论 对ACPE 患者应在血流动力学监测下进行药物干预及无创? 有创机械通气治疗, 宜采用压力控制模式, 个

    体化调节PEEP, 一般6～ 15 cm H2O , 依据临床情况尽快过渡到自主通气模式, 对撤机困难者可应用CPA P

    PPS 模式。

    【关键词】 肺水肿, 心源性, 急性; 血流动力学; 机械通气

    Cl in ical study of mechan ical ven t ilat ion in acute cardiogen ic pulmonary edema pat ien ts ZH A N Chun, Q IN

    Y ing 2 z h i, ZH A N G N a2 x in, X U L ei, ZH A N G W ei . Intensive Care U nit, T ianj in T h ird Central H osp ital,T ianj in, 300170, Ch ina

    【Abstract】 Object ive To study the app licat ion of mechanical vent ilat ion in acute cardiogenic

    pulmonary edema (ACPE) , and compare the changes in hemodynam ics betw een cont inuous po sit ive airw ay

    p ressure2 p ropo r t ional p ressure suppo r t (CPA P PPS) w ith cont inuous po sit ive airw ay p ressure p ressure

    suppo r t vent ilat ion (CPA P PSV ). Methods Non2invasive and invasive vent ilat ion w ere perfo rmed in 77

    ACPE pat ients . A t the init iat ion of invasive vent ilat ion and the phase of low assist vent ilat ion in 61 pat ients

    w ho w ere t reated w ith mechanical vent ilat ion longer than 24 hours, hemodynam icsw asmonito red by par t ial

    CO 2 rebreath ingmethod (non2invasive cardiac output, N ICO ) cardiopulmonarymanagement system, and then

    compare the changes in the two k inds of vent ilat ion under medicinal intervent ion . Results Among 33 of 61

    ACPE pat ients underw ent non2invasive vent ilat ion, 24w ere successful, and the rat io w as 7217%. Among 33

    pat ients w ith invasive vent ilat ion ( including 5 in w hom vent ilat ion w as sw itched to non2invasive mode) ,11 failed . B iphasic po sit ive airw ay p ressure? p ressure suppo r t vent ilat ion (B IPA P? PSV ) w as used in p ressure

    cont ro lled vent ilat ion, w ith h igh p ressure (Ph igh) 16 24 cm H2O (1 cm H2O = 01098 kPa) , t ime of h igh

    p ressure ( Th igh ) 115 seconds, po sit ive end2 exp irato ry p ressure ( PEEP ) 6 15 cm H2O , f ract ional

    concent rat ion of insp ired oxygen (F iO 2 ) 015, cardiac output (CO )? cardiac index (C I) w as signif icant ly

    imp roved compared w ith tho se of init ial vent ilat ion in successful ones in invasive group , and the imp rovement

    w as mo re signif icant in PPS compared w ith PSV in low assist vent ilat ion (all P < 01001). Tho se in w hom

    invasive vent ilat ion w as failed had a low C I ( < 115 L ·m in- 1

    ·m - 2) even under drug intervent ion .

    Conclus ion Hemodynam ic monito r ing should be perfo rmed w hen medicinal intervent ion and

    non2invasive? invasive vent ilat ion are given to ACPE pat ients . P ressure cont ro lled vent ilat ion is

    recommended, and PEEP should be individualized (no rmally 6- 15 cm H2O ). Spontaneous vent ilat ion should

    be resto red as soon as po ssible, CPA P PPS mode is p ract icable in pat ients in w hom w eaning of mechanical

    vent ilat ion is diff icult .

    【Key words】 acute cardiogenic pulmonary edema; hemodynam ics; mechanicalvent ilat ion

    基金项目: 天津市自然科学基金资助项目(023612211)

    作者单位: 300170 天津市第三中心医院ICU , 天津市呼吸机治

    疗研究中心

    作者简介: 展春(1972 ) , 女(汉族) , 天津人, 博士研究生 ......